Morten Thronæs

Background: There is an insufficient knowledge base for optimal parenteral nutrition (PN) use for patients with incurable cancer, leading to vague guidelines and varied practices. The aim of the study is to describe the practices and actual outcomes of PN in patients with incurable cancer at Norwegian hospitals. Methods: This multicentre study retrospectively reviewed 507 deceased patients (>18 years) receiving PN between 2011 and 2017. Data were collected from PN initiation until death, and analyses were descriptive. Results: Fifty-one percent had upper and lower gastrointestinal cancers, and the main PN indications were insufficient intake (75%) and gastrointestinal malfunction (47%). Sixty-seven percent received no anticancer treatment. Forty-three (8%) received PN as temporary bridging to anticancer treatment, of whom fifteen (35%) resumed or initiated treatment. The median PN dose corresponded to 53% of estimated energy requirements, and 94% of the patients had complementary energy intake. The most common reason for discontinuation was expected imminent death (47%). While common symptoms during PN were nausea (52%), vomiting (46%), and oedema (37%), 15% reported improved wellbeing. Conclusions: In this real-world cohort, up to 80% of the patients would not meet the eligibility criteria of previous trials due to cancer diagnosis and treatment, gastrointestinal tract function, weight loss criteria or complications such as ascites. This study highlights the heterogeneity in how patients with incurable cancer receive PN, and emphasises the importance of individualised PN treatment, carefully and safely managed to meet the patients’ palliative care situation. Future real-world pragmatic patient-centred protocols bridging the gap between clinical trials and patients in clinical practice are warranted.

Prognosticating survival in palliative cancer patients has been a longstanding challenge. While different tools and approaches may ease prognostication, biological variability limits their accuracy. Assessment of physical status is important for prognostication, along with evaluating the degree of systemic inflammation and patient-reported symptom burden. The distribution of survival was examined among palliative cancer patients with different functional status (Eastern Cooperative Oncology Group Performance Status), inflammation-related markers (modified Glasgow prognostic score [mGPS]), and self-reported symptom intensities (the eleven-point numeric rating scale [0 – 10]). Physical status and biomarkers of systemic inflammatory responses yielded important prognostic information in patients with advanced cancer. Among 147 hospitalized patients, median survival was longer for those continuing anti-cancer treatment, those with better functional status, and those with normal levels of C-reactive protein and/or albumin. Regarding the functional status categories, patients with PS 2 exhibited the widest range of survival. All categories, except PS 4, included patients with actual survival of almost 1 year or more. In terms of inflammatory markers, the widest survival range was observed among patients with mGPS 0. All categories included patients with actual survival of more than half a year, and mGPS 0 and 1 included patients with survival of more than one and a half years. No statistically significant differences in survival were identified between patients with mild and higher intensities of the symptoms under investigation. A wide range of survival outcomes at the group level makes prognostication for individual patients particularly challenging.

Despite the high prevalence of insomnia in patients with advanced cancer, there are no randomized controlled trials on pharmacological interventions for insomnia in this group of patients. A variety of pharmacological agents is recommended to manage sleep disturbance for insomnia in the general population, but their efficacy and safety in adults with advanced cancer are not established. Thus, there is a need to evaluate the effectiveness of medications for insomnia in order to improve the evidence in patients with advanced cancer. One of the most used sleep medications at present in patients with cancer is zopiclone. This is a randomized, double-blind, placebo-controlled, parallel-group, multicenter trial. A total of 100 patients with metastatic cancer who report insomnia will be randomly allocated to zopiclone or placebo. The treatment duration with zopiclone/placebo is 6 consecutive nights. The primary endpoint is patient-reported sleep quality during the final study night (night 6) assessed on a numerical rating scale of 0–10, where 0 = Best sleep and 10 = Worst possible sleep. Secondary endpoints include the mean patient-reported total sleep time and sleep onset latency during the final study night (night 6). Results from this study on treatment of insomnia in advanced cancer will contribute to clinical decision-making and improve the treatment of sleep disturbance in this patient cohort. ClinicalTrials.gov, NCT02807922 . Registered on 21 June 2016.